Kessel bonney osteotomy aug 2017

Podiatric Surgery

Kessel-Bonney Osteotomy (Big Toe Joint Surgery) Introduction

This leaflet will explain what will happen when you come to the hospital for an operation to repair an arthritic big toe joint.

Why do I need this surgery?

This type of surgery is undertaken when pain and stiffness are experienced in the big toe joint and when the joint shows signs of early osteo-arthritic changes. Signs and symptoms include pain, formation of an extra bony bump (an osteophyte) and loss of space between the bones of the joint.

Surgery aims to preserve the joint by removing the surrounding joint bony bumps and to ‘decompress’ the joint. This alters the big toe position to make the most of the joint movement that is present. It also aims to reduce pain in the osteo-arthritic big toe joint, thus making walking and wearing footwear more comfortable. Movement at the joint does not always increase but normally the pain is reduced. Results show that 70% of patients have pain relief, 20% have improved symptoms and 10% experience no improvement and require further surgery.

What does surgery involve?

On the day of surgery you will be admitted to the ward and one of the nursing staff will check you in, take your blood pressure and perform any other tests that may be required. The surgeon will remind you of the surgical process and possible complications and ask you to sign a consent form. Your foot will be numbed via a series of injections around the ankle. You can eat before the operation as it will be performed under local anaesthetic only. At some point during the morning/afternoon you will be escorted to theatre. The operation will take about 30 minutes.

You may bring a personal music player or book with you.

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Throughout the operation you will have a tight band (called a tourniquet) around the ankle to keep the blood away from your foot. This is sometimes uncomfortable but is released immediately after the operation.

The wound is repaired with stitches that dissolve. Occasionally, if your skin is very sensitive, or you are prone to problem scarring you may need non-dissolvable stitches that need to be removed after two weeks.

After the operation you will be taken back to the ward and given a drink and something to eat. You will be advised regarding painkillers and once ready you will be discharged from the day surgery unit. You will be given a postoperative boot to wear.

You should not drive after foot surgery and should be accompanied home by a responsible adult.

You will be advised of your follow-up appointment date, either on the day or by letter in the post.

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Kessel-Bonney Osteotomy (Big Toe Joint Surgery) How will I feel afterwards?

Although long-acting local anaesthetic administered during the procedure will control most of the pain for about eight to 10 hours, you can expect some pain or discomfort after the operation. Painkillers will be discussed with you prior to your operation and you should bring these with you on the day of surgery.

Recovering from surgery The first two to three days You must rest with your foot elevated just above hip level.

Keep the dressing dry.

You will be given advice on how to keep the foot as comfortable as possible and exercises to keep the blood circulating during your recovery.

You should restrict your walking to going to the bathroom only, and must use crutches in the way shown. You may be able to bear a little weight on the foot carefully using just the heel.

If you experience pain, it is usually worst for the first two days. You will be given painkilling tablets to help control this. After two to three days this should begin to improve.

An X-ray will be needed before you return for your two week review appointment. You will be advised where to go for this.

Two to seven days You should aim to be moving around for 10 minutes within each hour (although not in one go) as required, resting with your foot elevated for the remaining 50 minutes. Do not go out of the house, drive or get your foot wet.

Two weeks after surgery Two weeks after the operation you must attend an outpatient appointment for removal of the dressing.

The skin should be healing well by this time and any non-dissolvable stitches will be removed. Your X-ray will be examined.

You should no longer need a bandage and will be able to wear a normal shoe again, but this shoe does need to be broad and comfortable, such as a trainer, because your foot will be quite swollen.

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At this stage you will no longer need crutches and can gradually increase your activities gently. You will still need to rest between your activities.

You will also be given a rigorous regime of exercises in order to regain strength and flexibility in the toe joint.

At two to eight weeks

You can normally start bathing the foot three days after stitch removal.

During this time the foot gradually returns to normal and you may be able to vary your footwear a little, (60% of patients have returned to roomy shoes at six weeks, and 90% by eight weeks).

There will still be noticeable swelling, especially towards the end of the day, which is quite normal at this stage.

Work: You may return to work after six weeks (depending on the type of work and footwear in which you are allowed to return). For certain jobs this could be an unrealistic expectation.

Driving: At six weeks you can generally return to driving, however you must be able to perform an emergency stop. Always check with your insurance company about when your policy covers you to drive.

Although normal everyday activities will be possible, sporting activities are still restricted at this stage.

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Kessel-Bonney Osteotomy (Big Toe Joint Surgery) Eight to 12 weeks after surgery The foot should now be comfortable and returning to normal but there may still be some slight swelling.

Sports: You can return to sporting activities / gym work at 12 weeks.

Six to 12 months after surgery The residual swelling should now be very slight, although the healing process continues for a year. You should be getting full benefit from the surgery.

All healing is complete at 12 months.

What are the possible risks and complications?

The outcome of surgery can never be guaranteed, and every operation carries potential risks. An audit of surgery within this unit has shown good results.

General complications of foot surgery Pain: There will be post-operative pain. For most people the pain passes after 24-48 hours and is tolerable with regular painkillers (following dosage recommendations).

Swelling: This is a normal outcome of any operation. The extent of post-operative swelling varies and cannot be predicted. In some people the swelling reduces within a matter of weeks and in others could take many months. Application of an ice pack greatly reduces swelling.

Infection: There is a small risk of infection with all surgery. If this occurs it will be treated with relevant antibiotics. Look out for redness and discharge from the wound.

Deep vein thrombosis (DVT): Also known as venous thromboembolism (VTE), this is a rare complication of foot surgery under local anaesthetic. The risk increases if you are having a general anaesthetic. There is also an increased risk if you smoke, take the contraceptive pill or HRT. Immobilising the leg in a cast also increases the risk of a DVT. If you have had a DVT in the past, please tell your surgeon. If you do have certain risk factors you will have an injection to thin your blood on the day of surgery. This might need to be repeated for up to seven days following surgery.

Complex regional pain syndrome (CRPS): This is a rare but difficult complication. It is an abnormal response of the nervous system to surgery but can happen after simple trauma. This can lead to a variety of painful sensations in the foot, which require medical and pain relieving techniques.

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Scarring: As a result of your surgery you will have a scar on your foot. To begin with the scar will be raised, red and sensitive but with time it will usually settle.

Specific complications of Kessel-Bonney osteotomy Recurrence of the deformity.

Continued joint ache / pain and / or stiffness.

Continued symptoms requiring a second operation. ‘Floating’ of the big toe, where it does not touch the floor.

Development of deformities / pain with the toe next to the big toe.

Transfer of pressure onto the ball of the foot causing pain (metatarsalgia).

Alteration of gait pattern causing other joint / muscular pain.

Screw irritation: if necessary, the screw can be removed with a second small operation.

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Kessel-Bonney Osteotomy (Big Toe Joint Surgery) Delayed or non-union of the repositioned bone surfaces.

Localised bone death as a result of reduced blood supply to the bone (avascular necrosis).

Osteo-arthritic changes to adjacent joints.

Areas of numbness: This may reduce over 18 months.

Rarely, you may feel the foot is worse after surgery than it was before.

You should be aware that these complications are relatively uncommon. They mostly resolve without permanent disability or pain using medications, therapy and on occasions further surgery, but even allowing for these, sometimes you may not achieve the result that you want.

For these reasons we do NOT advise surgery purely for cosmetic reasons. We also advise against prophylactic surgery (which is preventative surgery to avoid problems that are not yet present).

Useful numbers Braintree Community Hospital

Podiatric Day Surgery Unit

01376 555 900

01376 555 908

If you have any concerns during the first 24 hours following your discharge from hospital, please telephone the ward you were on. After 24 hours, please seek advice from your GP. This document can be made available in other languages and formats upon request.

Podiatric Surgery at Braintree Community Hospital, April 2015. Review due: July 2019

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